Insurance Delay Forces Sick Woman Back To Square One

November 20, 1990|By Peter Hermann | Peter Hermann,Staff writer

Judy Marsh is all set to drive to Duke University Medical Center in North Carolina for a medical procedure that could cure her of cancer. But she has had to wait for Blue Cross/Blue Shield to decide if it will pay for the procedure.

Judy Marsh is tired of waiting.

Her family has waited. Her lawyer has waited. Aides to U.S.

Representative Tom McMillen, D-4th District, have waited. And still no answer from the insurance company.

"I can't wait for them anymore," Marsh said yesterday after returning home from a visit to her doctor at the University of Maryland Cancer Center in Baltimore, where she was discussing other ways to rid her body of the breast cancer that has now spread to her lungs.

Blue Cross first told the 49-year-old Pasadena woman she was covered, then told her she was not because the procedure was deemed "experimental."

The company's headquarters in Washington is reviewing her file.

But with a deadline looming and no answer from Blue Cross, Marsh has decided to pursue other ways of staying alive.

The procedure her doctors say offers her best chance at fighting the cancer is a autologous bone marrow transplant, in which her bone marrow would be removed, frozen and filtered back into her body after high doses of chemotherapy are administered to it.

To prepare for the procedure, Marsh had to undergo months of painful tests -- all of which could be for nothing if she does not have the bone marrow transplant soon.

Her lawyer, Richard Carter of Alexandria, has been waiting for the Federal Blue Cross/Blue Shied Benefits Program in Washington to finish reviewing Marsh's file and issue a ruling. Marsh is covered under a federal insurance package because her husband was a federal employee.

But Robert Flohr, director of claims services for the federal program, said Friday he did not know there was a deadline. "We are still in communication with Duke Medical Center," he said. "There has been no further action."

The procedure itself is risky, but if it works, the high levels of chemotherapy could kill the cancer cells. Conventional chemotherapy has failed to do that since Marsh discovered she had the disease in 1988.

But officials with Blue Cross say the procedure is experimental and have just announced they will start conducting clinical trials at various hospitals. Under the trials, Blue Cross will pay for people to have the procedure, which can cost up to $170,000.

"We need medical evidence to see if it does work," said Judy Boyles, spokeswoman for the Blue Cross/Blue Shield Association, based in Chicago.

"The procedure is very dangerous. It kills 10 percent of the people who get it. We want to pay for things that work. That's why we made an exception to do the clinical tests."

But that won't help Marsh; Blue Cross says it won't start until next year, and even then there is no guarantee Marsh would be considered.

Liz Wagner, an aid to McMillen who has helped women in the state get Blue Cross to pay for the transplant, is frustrated by Marsh's case. She points to a letter she received from the American Medical Association, which says the AMA does not consider the procedure experimental.

Stephanie Bass, spokesman for the cancer center at Duke University, said the procedure is an "established therapy. It is not a procedure for everybody, but 'experimental' is not a term we use."

Dr. Jeff Abrams, Marsh's doctor and a professor at the University of Maryland Cancer Center, said the procedure is "investigative. I don't think it is experimental in terms that it has never been done or it has never been successful. How it will help Marsh is unknown at this point."

He said Marsh could wait until the end of the month to have the procedure, but agreed she needs some kind of treatment soon. He said Duke has only a certain number of available slots for the procedure, and they are filling up fast.

Marsh had thought about suing Blue Cross; at least three other Anne Arundel residents faced with same predicament sued and won, forcing the insurance company to pay $100,000 toward the treatment. For one woman, the victory in court came to late: She is now in a holistic treatment center in Pennsylvania.

Abrams and Marsh met yesterday to discuss what will be done next. He said Marsh is looking at other types of investigative treatment. But the question remains: How will Marsh pay?